If Michael Ain believed in playing the odds, he never would have
become a doctor. Rejection letters from more than 20 medical
schools--as Ain received--would have convinced most people to
change career plans.

But more than anything else, Ain wanted to be a doctor. He was
smart and knew he could do the job. Being only 4 feet 3 inches,
he staunchly believed, should not affect how his dice were
cast.

Fortunately, the odds do not always prevail. Which is why now, on
a rainy day in January, Ain slips on a pair of sterile surgical
gloves, climbs up onto a step stool, and calls out, "Scalpel."

Proving the naysayers wrong: Ain was
rejected by two dozen residency programs on the basis that
he wasn't physically up to the job. Today at Hopkins, his
surgical card is full. The adjustments have been minor--a
stool in the O.R. and specially tailored surgical
gowns.

FROM A DEMOGRAPHIC PERSPECTIVE, Ain, 38, is remarkable. A
pediatric orthopedic surgeon at Johns Hopkins Hospital, he is one
of only a handful of physicians in the country who are dwarfs. He
may be the only dwarf in the world who is an orthopedic surgeon,
a field that has the reputation of being the rough and rugged
medical specialty.

But to Ain, the day-to-day adjustments that enable him to do his
job and thus be remarkable are really quite simple. "To be very
honest, the only special things I need are a stool in the O.R.,
and I have special gowns tailored that are shorter."

On this particular day, Ain is straightening and fusing the
severely crooked spine of a 10-year-old girl named Stephanie. The
girl has congenital scoliosis that is progressively getting more
pronounced. Fusion will prevent her spine from curving into a
painful deformity. "We're doing an anterior and posterior,"
explains Ain, meaning that he will access her spine first through
her chest and then through her back.

Ain made the first incision at 9 a.m. He now removes Stephanie's
right sixth rib, gaining access to the spine. The rib will also
provide the implantable material that he'll use to promote the
spinal fusion. Reaching through the chest, Ain removes five of
Stephanie's disks, the cushiony material between vertebrae, and
inserts slices of the rib in their place. He and visiting
resident Michael Mann then stitch Stephanie back up.

Ain's hands are muscular. He works with concentration,
alternately offering instruction to Mann and punctuating these
lessons with banter and bad jokes. At one point, I ask whether
the patient will live comfortably without one of her ribs. His
eyes twinkling above his surgical mask, Ain replies, "Adam lost a
rib, didn't he?"

By noon, the first half of the operation is complete.

What are the odds?

A few years ago, geneticists determined that
achondroplasia results from a mutation on the fibroblast
growth factor receptor-3 (FGFR3) gene on chromosome 4. "This
site seems to be the most mutable in the entire genome,"
says geneticist and pediatrician Michael Wright, acting
clinic director of the Greenberg Center for Skeletal
Dysplasia. The mutation is dominant and occurs in about one
out of 25,000 births. It is passed from one generation to
the next, or may result from a new mutation. In Michael
Ain's case, where neither of his parents is an
achondroplast, the mutation seems to have occurred anew.

If an achondroplastic dwarf marries a person of average
stature, there is a 50 percent chance that their child will
be a dwarf. If two achondroplasts marry, there is a 50
percent chance that their child will inherit a single copy
of the gene for achondroplasia, and thus be a dwarf. There
is a 25 percent chance that their child will be of average
stature. And there is a 25 percent chance that their child
will inherit two copies of the gene. Such "double-dominant"
offspring die in utero or before age one.

"Okay, like we've never been here," says Ain, ordering his O.R.
staff to change scrubs and surgical gloves. After putting on a
fresh gown and gloves himself, Ain climbs onto his step stool. He
and Mann turn Stephanie onto her stomach and begin phase two of
the operation. They will fuse Stephanie's spine using small
surgical hooks and rods, inserting more slices of the rib between
adjoining vertebrae. "The rib helps the fusion because it is
bone," explains Ain.

It will be nightfall by the time Ain completes the operation.

MICHAEL AIN TREATS PATIENTS who have a wide variety of orthopedic
illnesses and injuries, from fractured tibia to club feet, but he
specializes in the orthopedic problems of dwarfism and related
disorders. He fuses painfully curved spines, reduces bones that
compress the spinal cord, and performs other procedures for
complications that can result from these disorders. In medical
terms these conditions are called skeletal dysplasia--literally
abnormal growth or development of the bones. Skeletal dysplasia
is a grab bag of more than 100 different disorders, most of which
cause short stature.

The bulk of people with skeletal dysplasia, including Ain, have a
form of dwarfism called achondroplasia. Achondroplastic dwarfs
have an average size trunk, but their limbs are shorter than
average and often their head is enlarged. Many also have bowed
legs and swaybacks. On average, they grow to about 4 feet to 4
feet 3 inches. (In contrast, people with dwarfism stemming from
an endocrine dysfunction are extremely short-statured but have
limbs that are proportional to their trunk size.)

While achondroplasia does not affect intelligence, it can
contribute to a host of medical problems ranging from chronic ear
infections to potentially fatal compression of the spine. Hopkins
is one of the world's leading medical centers for patients with
achondroplasia and other forms of skeletal dysplasia. Dwarfs from
all over the world visit Hopkins for medical care, which is
coordinated through the Greenberg Center for Skeletal Dysplasia,
named for philanthropists Alan C. and Kathryn Greenberg.

Ain is upbeat and friendly and adept at explaining medicine in
plain English, traits that endear him to many patients. But he
means something special to his patients who are dwarfs, like
26-year-old Heather Davis. "I'm glad he can get beyond the
barriers and has dedicated his life to helping people," says
Davis, who was Ain's surgical patient two years ago and is now a
graduate student at the University of Minnesota.

Marie Bieniek, mother of 5-year-old Andrew, says her son "adores"
Dr. Ain. Andrew has traveled with his parents to Hopkins several
times to be treated for complications of dwarfism. In September,
Ain straightened Andrew's severely bowed legs.

"Some doctors think they can try to make him normal," says
Bieniek. "Dr. Ain knows Andrew is normal already. He wants to
keep him healthy."

A visitor meeting Ain for the first time almost expects to
encounter a saint. So it is somewhat refreshing to find that he
is an unpretentious mortal with a Long Island accent.

Being cast as a role model, says Ain, makes him uncomfortable. "I
try to downplay it," he says with a shrug.

Ain grew up in Roslyn Heights, Long Island, where his parents
still live. His father is a lawyer, and his mother is a travel
agent. Neither is a dwarf.

Five-year-old Andrew Bieniek "adores"
the upbeat Dr. Ain, according to his mother, Marie. The
little boy has traveled to Hopkins several times to be
treated for complications of dwarfism; last fall Ain
straightened Andrew's severely bowed legs.

"When I was growing up, I didn't have role models who were
dwarfs," he says. "My mother and father were good role models,
great role models. They were very wonderful, always encouraging.
Being short could never be used as an excuse--if I came home and
didn't make the basketball team or get an A. They always
instilled in me I could do anything I wanted to."

As a child, Ain saw a fair share of doctors and made a trek every
year to Johns Hopkins Hospital to be examined by medical
geneticist Victor McKusick, who diagnosed Ain's condition. Ain
did not require serious medical interventions, aside from having
ear ventilation tubes implanted, a procedure prescribed for many
achondroplasts. (Having a smaller throat and nasal passages
appears to impede ventilation, which raises the risk of middle
ear infections.) However, young Michael spent enough time in
examining rooms to experience a callous side of doctoring. Some
doctors, says Ain, "used to talk in the third person: 'Michael's
drainage output this, this, and this.' They'd kind of talk about
you."

In school, he experienced the teasing that most "little people"
go through. But he has always been outgoing and made friends
easily. He and eight childhood friends get together every year
for a reunion.

After attending Andover Academy in Massachusetts, Ain went to
Brown University, where he decided he wanted to become a doctor.
"I thought medicine was a fascinating field, a chance to help
people." Having been a patient himself, he felt, would also be an
advantage. He was determined to have a better bedside manner than
many of the doctors who treated him when he was a child.

At Brown, Ain built the solid academic and extracurricular record
that medical schools seek in their applicants. He majored in
math, earning a better-than-B average, did research in a
physiology lab, and earned good MCAT scores. He also played
second base on the varsity baseball team, co-directed the
university's Big Brother program, and was an officer in his
fraternity. Ain sent out 20 to 30 applications to medical schools
all over the country including Hopkins. On the advice of a
guidance counselor, he noted in the personal letter each school
required that he was a dwarf. "Because I am," Ain says simply.
"It shaped me."

At first he thought he had a good chance of getting into medical
school. But then his optimism began to fade. During several of
his admissions interviews, officials told him he'd have great
physical difficulty performing the duties of a physician. When
Ain pressed them to explain, they told him he would not be able
to reach his patients' bedside. To Ain, the solution seemed
obvious. He would use a footstool. Others worried that he wasn't
strong enough. Ain, who had been lifting weights and working out
regularly, fired back, "I'm stronger than anybody you're
interviewing today." He suggested he could match any of them in
the weight room. What about gaining the respect of his patients?
asked some interviewers. Ain thought that was a lame excuse. His
classmates at Andover had chosen him to receive the coveted "End
of the Year Award," signifying their respect and admiration. He
had proved his leadership skills time and again. "You don't have
to be intimidating to be respected," Ain says.

But Ain's fears were confirmed. One by one, the thin envelopes
bearing rejection notices arrived, until eventually Ain had
received one from every medical school to which he had
applied.

Ain was devastated. Although none of the letters mentioned his
height, he had no doubt that some or all of the admissions
offices believed a dwarf could not or should not become a
physician.

"I was scared. I was angry. I was hurt. It was the only time I
hit the wall," he says. "It was the only time I felt trapped."

The experience challenged his whole outlook. "I was being denied
this for no good reason, for a reason I couldn't do anything
about. It goes against everything I was taught. My parents told
me I could do anything I wanted as long as I pushed myself. If
this was going to happen, then during the first 23 years of my
life, this lie was being made."

Ain decided to try again. He returned to Brown the year after he
had graduated to try to improve his chances of getting into
medical school. He took two advanced science courses, earning two
A's with distinction. He continued his research and got his work
published. He applied to about 20 medical schools, including some
of the same ones he had applied to the first time, again frankly
revealing that he was a dwarf.

Again the thin envelopes began arriving. But this time, one
envelope was fatter than the others. It was an acceptance from
Albany Medical College in upstate New York.

One of the Albany faculty members who interviewed Ain was B.
Barry Greenhouse, then an associate professor of anesthesiology.
Greenhouse and Ain hit it off. Greenhouse was a baseball fan and
was impressed that when Ain played for Brown he had batted
against Ron Darling, the Yale player who went on to become a
famous Mets pitcher. Moreover, says Greenhouse, "I just felt he
was a good student. He impressed me immensely with his
intelligence. He was a compassionate, decent young man who would
be a credit to the medical profession. If I were ill, I would
like him to be my doctor."

Getting a straight answer

When Michael Ain was 19, he underwent a
surgical procedure known as an osteotomy to straighten his
bowed legs. It involved breaking and resetting the legs. The
procedure caused Ain a good deal of pain, and he lay in a
body cast for several months.

A wrestling injury prompted Ain's surgery, but doctors
recommend the procedure to many achondroplasts with bowed
legs to reduce their chances of arthritis.

Now that he is an orthopedic surgeon, Ain suspects that this
medical premise may not apply to all achondroplastic dwarfs,
about half of whom have the condition. "I think many
[achondroplasts] do not need any type of treatment," he
says.

The link between bowing and arthritis is based on research
involving patients of average stature, Ain notes. Bowing may
increase pressure at the knee joint, setting the stage for
arthritis. But because achondroplasts have shorter limbs,
they may not have the same degree of risk, suggests Ain.

To test this theory, he and biomedical engineer Edmund Chao
are creating a biomechanical computer model of
bowleggedness. Ain is also conducting clinical studies in
achondroplasts older than 40 to see whether the amount of
arthritis the patients have correlates with their degree of
bowleggedness.--MH

Ain did well at Albany and decided while he was there that he
wanted to become a pediatric neurosurgeon. He was an avid
woodworker and had always enjoyed working with his hands. And he
liked the immediate gratification such surgery provided. Ain
applied to 14 residency programs, had nine interviews, and was
rejected by every program. He then applied to nine or 10 general
surgery residencies, including some "bottom of the barrel
programs" to which a candidate with inferior credentials would
have been admitted. Again, they turned him down.

The gatekeepers of the residency programs were blunt. "Every
place one guy said, 'You can't do it physically' or 'Patients
won't respect you,'" recalls Ain.

Ain spent the next year doing a pediatrics residency at the
University of California at Irvine. Though he enjoyed working
with children, he still yearned to be in the operating room. So
Ain wrote to John Hall, a renowned pediatric orthopedic surgeon
at Children's Hospital in Boston, who had done surgery to
straighten Ain's bowed legs when Ain was 19. When Ain was in
medical school, he had done a rotation at Children's under Hall's
supervision. In his letter to Hall, Ain asked what his chances
would be of getting into an orthopedic surgery residency. Hall
was encouraging, and Ain applied to two residencies. He was
considering a third, but the chairman at that program told him,
"There's no way you're going to get in. You should be quite happy
doing pediatrics," Ain recalls.

But the chairman at Albany Medical College did not see it that
way. Richard Jacobs, who is now retired, told Ain, "If your
record is as good as everybody else's, you'll get in. It doesn't
matter whether you're 4 feet 3 inches or 6 feet 3
inches. We will take you." After examining Ain's record, Albany
accepted him.

In entering the ranks of orthopedic surgery, Ain was indeed
standing certain assumptions on their heads. Of all the
specialties, orthopedics has a machismo reputation--not without
some justification. It takes a fair amount of strength to push
and pull fractured bones back into place. When a patient has
dislocated a hip, for instance, an orthopedist has to lift the
patient's leg and push against muscle and soft tissue to force
the hip back into the socket. The tools of orthopedic surgery are
bold and serious affairs. An orthopedic cart parked in the
Hopkins operating suite resembles a medieval hardware store:
drills, saws, reamers, mallets, hooks, rods, and screws--tools
for cutting bone, reducing fractures, drilling holes for
screws.

During his five-year residency at Albany, Ain proved he could do
the job, says Allen Carl, an associate professor of surgery at
Albany who was one of Ain's mentors. "He's just a wonderful
person who exudes the positive," notes Carl.

While at Albany, Ain also began dating a nurse named Valerie
Frinks, who, at 5 feet 6 inches, is of average stature. They
married and now have a 2-year-old daughter, Alexa. Their daughter
is a little person, says Ain, and he does not want to discuss her
size in any more detail than that. "She is the most delightful,
beautiful person," he adds.

At first, Ain thought he might become a hand or joint surgeon. He
never considered specializing in bone disorders such as
achondroplasia. "It's the last thing in the world I wanted to do
because it's like looking in the mirror every day," he says.

That feeling changed one day in the operating room, when Carl
mentioned to Ain that he had read a newspaper article about a
couple from southern California who had an achondroplastic
daughter. The parents were worried about the limitations their
child would face. (After all, notes Ain, "Where do you see most
little people? On TV, at the circus.") But the father had been
encouraged when he met a physician at a party who was an
achondroplast. If this man could become a physician, the father
reasoned, then his daughter could have many opportunities in her
life.

Ain suddenly realized that he was the physician at that
party.

An improved outlook

Today, physicians know a lot more about some
of the more serious complications of dwarfism than they did
a decade ago, when 8 percent of children with achondroplasia
died before age 5. Many of these children died suddenly, and
the cause was a mystery. But researchers now suspect that
undersized bone structure set the stage for many of these
deaths, says Hopkins's Michael Wright. The culprit appears
to be an opening at the base of the skull, called the
foramen magnum, through which the spinal cord connects to
the brain. In some achondroplastic babies, the foramen
magnum is so narrow that it clamps down on the spinal cord
where it meets the brain stem, compromising the nerves that
control breathing. In the worst cases, babies stop breathing
and die.

Through a surgical technique refined by Hopkins pediatric
neurosurgeon Ben Carson, many of these babies are now
spared. Carson enlarges the foramen magnum to make more room
for the spinal cord. It appears that the improved surgical
technique, in addition to better diagnosis of babies at risk
for foramen magnum compression, is saving more babies, says
Wright. Today the mortality rate for achondroplasts under
age 5 is just 1 percent.

Ain and Hopkins neurosurgeon Daniele Rigamonti perform a
similar surgical procedure on the lower portion of the
spine, where undersized vertebrae can impinge on the spinal
cord. This condition affects adult dwarfs more than it does
children, causing back pain and in the worst cases
preventing mobility.--MH

"So at that point, without sounding corny," says Ain, "I thought,
there are a lot of good hand and joint surgeons. If I could have
an effect, help people, or be able to sympathize and understand
certain issues, then maybe that's why God wanted me to become an
orthopedic surgeon. Maybe this is it."

So Ain applied for a fellowship in orthopedic surgery at Hopkins,
where director of pediatric orthopedics Paul Sponseller was eager
to build a program in skeletal dysplasias. Sponseller had no
hesitation about hiring Ain. "We thought Michael would be a good
candidate," says Sponseller. "I was reassured to my satisfaction
by people in his residency that he was capable of doing
surgery."

AIN SEES PATIENTS at the Hopkins orthopedic clinic on Mondays.
One recent Monday, at least 30 patients visit the fifth floor
clinic in the Outpatient Center. Anything that could possibly go
wrong with a bone--breaks, infections, wasting conditions--is
seen in the clinic's warren of examining rooms.

Ain's patients include a 7-year-old child with a leg problem
known as Perthes avascular necrosis that is dissolving the head
of her femur; a chubby 5-year-old named Jason who fractured
his tibia and femur in an auto accident several months earlier; a
young boy with an arm fracture that is healing nicely; a
2-year-old girl whose cerebral palsy freezes movement in her left
leg; and a toddler who was born with club feet that Ain
surgically realigned several weeks earlier.

In this age of sophisticated medical technology, an orthopedist's
hands are still an important tool. One of Ain's patients in
clinic this day is 5-week-old Emma, a pink-cheeked, healthy
looking baby. Clasping one of Emma's legs in each of his hands,
Ain gently moves them from side to side, sensing through his
touch whether Emma's hips are properly aligned. Emma was born
with developmental dysplasia of the hips, meaning her legs slip
in and out of the hip sockets. She is wearing a special harness
over her legs and tummy that is designed to fix her hip joints in
place over the next several weeks. The baby's mom asks Ain why
her daughter was born with this condition. He replies that for
some unknown reason, developmental dysplasia of the hip occurs
most commonly among first-born girls who are breech babies, as
Emma was. "It's the way God smiled upon her," Ain says.

Ain gently teases nervous children and their parents, and
sharpens the edge of his banter when the target is a
colleague.

Occasionally, a child will ask him why he is so short, says Ain.
His standard reply: "I never grew as fast as everyone else." Most
adults do not remark about his height.

"I really have a lot of confidence in him," says Jackie Scott,
the mother of one of the patients Ain sees that day. "He is
personable and funny and does put you at ease. He doesn't make
you feel he's pressed for time and has got to go. That's very
important."

One of the last cases of the day is the most complex. Two
brothers and their sister have OSMED syndrome, a rare genetic
form of skeletal dysplasia reported in only a handful of cases.
The children, along with their parents and a sister who does not
have the disease, have come from the United Arab Emirates to be
seen by a retinue of Hopkins experts.

The children have abnormally weak collagen, which contributes to
a slew of medical problems including cleft palate, knobby joints,
and a dip in the chest that could pose a danger if it presses on
the heart. They are small for their age, though within the normal
range.

Even on the craziest days, Ain loves
what he does. "I'm able to foster caring for people," he
says. "I like the immediate gratification of
surgery."

The syndrome is not life threatening, but it predisposes them to
premature arthritis and scoliosis. It also impairs hearing. The
three children with the syndrome are wearing hearing aids. They
have developed their own sign language and gesture to each other
while waiting for Ain to examine them. When Ain enters the
examining room, they stop gesturing and look at him timidly.

"Hi. Hello," says Ain, looking around as though he doesn't know
where to start. "From an orthopedic point of view, what are your
concerns?" he asks the children's father.

"Their joints. All. They are painful sometimes. And will they
grow?" the children's father replies through an interpreter.

One by one, Ain examines each child, asking gentle questions as
he goes. The process is tedious, involving two sets of
translations, from sign language into Arabic, and from Arabic
into English, and vice versa.

Ain orders an extensive set of X-rays for each child, then tells
the family he'll see them in a few hours after the films have
been taken.

Back in his office, he shuffles through patient files. "I have a
headache," he tells a nurse. "A huge headache." The family with
OSMED syndrome has pushed his schedule way behind. In the
meantime, there are two more patients with complex cases of
skeletal dysplasia waiting to see him. He needs to see X-rays of
another patient, but that patient's HMO refuses to cover
radiation charges incurred outside its own offices. Frowning, Ain
picks up a patient file from his desk and walks into the next
examining room.

The next day, Ain apologizes for being irritable. "That's about
as cranky as I ever get," he says. Even on the craziest days,
says Ain, he loves what he does. "I like being at Hopkins. It's a
center of excellence. I like working with the people I work with.
I'm able to foster caring for people. I like the immediate
gratification of surgery." He has arrived, he says, where he
wanted to be.

For a long time Ain saved all the rejection letters he had
received from medical schools. Perhaps one day, he thought, he
would write back to those schools to tell them that he had defied
their odds. Over the years, however, his anger faded. He mellowed
and lost track of the letters. It's no longer important to tell
people he can do the job. Now he just shows them.